Organization
SOUTHERN CROSS SURGERY CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. R. L. TALLEY JR. MD (MD/OWNER)
(770) 760-9360
Entity
Organization
Contact information
Practice address
1301 SIGMAN RD NE, SUITE 120, CONYERS, GA 30012-3812
(770) 760-9360
Mailing address
1301 SIGMAN RD NE, SUITE 120, CONYERS, GA 30012-3812
(770) 760-9360
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
29957
GA
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
029957
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
202G490818
MEDICARE PTAN
GA
Enumeration date
05/19/2011
Last updated
04/29/2015
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